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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN - PHONE (209)468-3420 <br /> P O BOX 2009, 3TOCKTON, CA 95201. <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby rnade.to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County; Public Health Services. / A 10 <br /> ®b- (/ �J _ City Size/Acreage <br /> ('Job Address <br /> / `S 73//-7 <br /> ddress 7 /t /` Phqe9 <br /> Owner's Name 0,ALense No. Phone S <br /> 7 <br /> Vess <br /> ✓(ContractorU LJI—DU <br /> S <br /> TYPE FF—WELL'/PUMP: NEW WELL ❑r WELL REPLACEMENT ❑ DESTRUCTION CllOut of,3toring Well ❑'> <br /> OTHER 13 <br /> Monitoring 41e11 ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL —.OTHER WELL—"PITS/SUMPS ' <br /> INTENDED USE TYPE OF WELL.. PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia- of Well Excavation <br /> Cl Industrial ❑ Open Bottom ❑ Manteca <br /> Dia. of Well Casing <br /> Type of Casing_ Specifications <br /> C7 Domestic]Private ❑ Gravel Pack L7 Tracy e Type of Grout - <br /> ('I Public f-1 Other P Delta 'Depth of Grout"Seal <br /> 4 I I Irrigation _.Approx. Depth l I Eastern Surface Send Installed by <br /> I of Pump H.P. — State Work Done <br /> 4 Repair Work Done U Type Sealing Material i Depth <br /> Well Destruction ❑ Well Diameter <br /> Depth 6 Filler Material i Depth <br /> YPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITIODESTRUCTION I I (No <br /> ailwithin 200 teet�)ed if public sewer is <br /> N I <br /> installation will serve: R 'dence 1� C mmercial ther <br /> Number of living units: Number o rooms <br /> ' Water table depth <br /> Character of soil to a depth of 3 feet: I <br /> SEPTIC TANK <br /> XType/Mfg `xCapacity t,L -- No. Compartments <br /> i <br /> r Method of Disposal <br /> PKG. TREATMENT PLT. ❑ / <br /> Distance to-nearest: 611 Foundation—�r---XProperty Line <br /> _t <br /> 125 7 <br /> -� <br /> -- - r �, r — .. - -" - ;Total fengt lsize O <br /> LEACHING LINE No. & Lehgtli'of lines ,. F <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Lino <br /> 1 - <br /> SEEPAGE PITS I i Depth ` Size umber <br /> SUMPS �Distance to nearest: Well + 1—r Fou`�l n t Property Line <br /> DISPOSAL PODS ❑ <br /> certify, that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued. I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of lifornia." <br /> T e applica t ust call for at r d in ctions. Complete drawing on reverse side. 7 <br /> n� <br /> Signed X Title: Date: <br /> FO DEPARTMENT USE ONLY <br /> Date Area l <br /> Application Accepted by ► / 3 <br /> Pi otional <br /> Grqut lnapaCtlon byDate Final Inspection by Date <br /> dl Comments: <br /> Applicant -'Return all copies to: San Joaquin Coun y Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEECK RECEIVED BY DATE PERMi7'NO. <br /> INFO <br /> UE AMOUNT REMITTED CUASH(D 2 .110 <br /> t , EH 13.24IREY.1iK51 <br /> !f EH 14-20 <br />